Provider Demographics
NPI:1831744838
Name:FORMAN, AMANDA ELHILOW (RDN)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:ELHILOW
Last Name:FORMAN
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1108 31ST DR APT 316
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11106-5077
Mailing Address - Country:US
Mailing Address - Phone:516-884-8433
Mailing Address - Fax:
Practice Address - Street 1:2175 WANTAGH AVE
Practice Address - Street 2:
Practice Address - City:WANTAGH
Practice Address - State:NY
Practice Address - Zip Code:11793-3972
Practice Address - Country:US
Practice Address - Phone:516-344-5542
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-06
Last Update Date:2019-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
86074759133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered